=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275921280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESTINEE SHARAE MOORE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2014
-----------------------------------------------------
Last Update Date | 04/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N MICHIGAN AVE STE 1025
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-3756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-521-0167
-----------------------------------------------------
Fax | 708-843-9384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1245 S MICHIGAN AVE UNIT 161
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-521-0167
-----------------------------------------------------
Fax | 708-843-9384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149017231
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------